GIM

Question 1

Medications causing Lower limb edema

Answer 1

• The drugs most commonly implicated in edema formation are calcium channel blockers, gabapentin, NSAIDS, oral contraceptives, glucocorticoids, and thiazolidinedi- ones.

Answer 2

• If scaphoid fracture is suspected and radiographs are normal, thumb splinting and repeat radiography in 1 to 2 weeks or immediate advanced imaging (MRI or CT) (the latter is the preferred approach)

Question 3

Binge eating disorder management

Answer 3

• Cognitive behavioral therapy is the cornerstone of treatment for binge eating disorder.

• Lisdexamfetamine reduces the frequency of binge eating days and can be added as an adjunctive treatment for patients with persistent symptoms of binge eating disorder.

SSRIs will cause weight gain

Question 4

Venous ulcer treatment

Answer 4

🔴Treatment of venous stasis ulcers consists of local wound care and compression therapy.
🔴Infection should be eliminated as a contributing cause of nonheal- ing venous ulceration.
🔴Necrotic tissue should be debrided, and the wound should be covered with a dressing.
🔴Various dressings are available, and none stand out as superior in direct comparisons; however, dry gauze should be avoided because it disrupts the formation of granulation tissue when removed.
🔴Compression therapy is an essential component of the treatment of venous stasis ulcers. Before application, measurement of the (ABI) is recommended to avoid inappropriate application of lower extremity compression in a patient with peripheral artery disease. An absolute contraindication to compression therapy is an ABI of 0.5 or less,

Question 5

PTSD Management

Answer 5

Cognitive behavioral therapy is the cornerstone of therapy for patients with posttraumatic stress disorder.

• Sertraline, paroxetine, and venlafaxine, in conjunction with cognitive behavioral therapy, may help relieve posttraumatic stress disorder symptoms.

Question 6

Premenstrual dysphoric disorder

Answer 6

• Premenstrual dysphoric disorder consists of symptoms of mood disturbance that develop the week before menses, remit within a week after menses, and occur with most menstrual cycles during a given year.

• First-line therapy for premenstrual dysphoric disorder includes second-generation antidepressants with special emphasis on safety in pregnancy

Question 7

Opioid overdose risk

Answer 7

• Major risk factors for opioid overdose include receiving more than 50 morphine milligram equivalents per day and receiving opioids and benzodiazepines concurrently.

Question 8

Alcohol withdrawal management

Answer 8

• The treatment of severe alcohol withdrawal symptoms is best managed by symptom-triggered administration of benzodiazepines.

• In the treatment of severe alcohol withdrawal symp- toms, short-acting benzodiazepines are preferred to long-acting benzodiazepines in patients with severe alcoholic hepatitis or cirrhosis.

Question 9

Thoracic outlets syndrome keywords

Answer 9

Neurogenic: Weakness and numbness and parsthesia with widespread (overhead movements)

Question 10

Chronic insomnia management

Answer 10

• For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or who decline to participate in CBT-I, either low-dose doxepin or a nonbenzodiazepine benzodiazepine receptor agonist (e.g., zolpidem, zaleplon, eszopi- clone) is recommended after a discussion of risks and benefits

Question 11

Chronic cough approach

Answer 11

• The initial management of chronic cough includes tobacco cessation and discontinuation of ACE inhibi- tor therapy, followed by chest radiography if cough persists.

• In patients with negative findings on chest radiograph and persistence of cough after discontinuation of ACE inhibitor therapy and tobacco, additional evaluation proceeds in a stepwise fashion: (1) empiric treatment for upper airway cough syndrome; (2) spirometry or empiric treatment for asthma; (3) sputum analysis for eosinophils or empiric treatment with inhaled glucocorticoids; and (4) empiric treatment for gastroesoph- ageal reflux disease.

Question 12

Post menopausal Vaginal atrophy management

Answer 12

• The North American Menopause Society recommends initiating nonhormonal therapies, such as daily vaginal moisturizer and vaginal lubricants, as first-line treatments for genitourinary syndrome of menopause before considering topical vagínal estrogen therapy
If nonhormonal treatments are not effective in the treatment of genitourinary syndrome of menopause, guidelines recommend the use of low-dose topical vaginal estrogen therapy rather than systemic estrogen therapy for patients whose only symptoms are related to vaginal atrophy.

Question 13

Suspected melanoma work up

Answer 13

• For suspected malignant melanoma, excisional biopsy, a technique in which the entire lesion is removed using 1- to 2-mm peripheral margins, is used for both diagnosis and determination of Breslow depth

Question 14

Recombinant herpes zoster vaccine

Answer 14

• Adults aged 50 years or older should receive the recombinant herpes zoster vaccine regardless of a his- tory of herpes zoster vaccination with the live attenuated vaccine or a previous episode of herpes zoster.

Question 15

Pre-op management of biologics and DMARDs

Answer 15

• All nonbiologic disease-modifying antirheumatic drugs should be continued throughout the periopera- tive period in patients with rheumatologic disease undergoing elective arthroplasty.

• Biologic agents should be withheld for one dosing cycle preoperatively, before arthroplasty, with surgery performed at the end of the cycle and resumed when the wound shows evidence of healing.

Question 16

Seborrheic keratosis treatment

Answer 16

Topical antifungal treatments are first- line treatment. Over-the-counter medications, such as zinc pyrithione and selenium sulfide shampoos, are the most cost-effective treatment options to use first. Ketoconazole shampoo and cream are also effective. Patients should apply the shampoo on the skin and allow it to sit for 5 minutes before rinsing it off.

Question 17

Contraindications for estrogen containing contraception

Answer 17

• Contraindications to estrogen-containing contracep- tives include migraine with aura, history of breast cancer, venous thromboembolic disease, uncontrolled hypertension, or smoking more than 15 cigarettes a day for women older than 35 years

Women with contraindications to estrogen should be prescribed either a progesterone-only or a non- hormonal contraceptive option

Question 18

Acute bacterial conjunctivitis treatment

Answer 18

. Trimethoprim- polymyxin ophthalmic solution is an appropriate antibiotic option. Other reasonable options are erythromycin or bacitracin-polymyxin ophthalmic ointments.

Because of concern about antibiotic resistance and higher cost, ofloxacin ophthalmic solution should be reserved for patients who wear contact lenses. which increases the risk for pseudomonal infection

Question 19

Erythroderma

Answer 19

• Erythroderma describes the condition of erythema covering greater than 80% body surface area.

• Up to 40% of cases of erythroderma are idiopathic; exacerbation of a preexisting rash (e.g., psoriasis, atopic dermatitis) and medication reaction are other common etiologies.

Question 20

Pregnancy and vaccination

Answer 20

🔴All women considering pregnancy should be assessed for immunity to varicella and rubella.

🔴If an already pregnant woman is not immune to either varicella or rubella, these vaccines should be administered after delivery and before hospital discharge

🔴Reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine between 27 weeks’ and 36 weeks’ gesta- tion with each pregnancy, helping to ensure immunity to the child upon birth. Administering Tdap during pregnancy is recommended regardless of when a patient received her last tetanus vaccination.

🔴Immunizations to be avoided during pregnancy include live vaccines (varicella, rubella, measles, mumps, live attenuated influenza, live attenuated herpes zoster) and human papillomavirus (HPV) vaccine.

Question 21

Pemphigus vulgaris vs bullous pemphigoid

Answer 21

• Pemphigoid vulgaris is an autoimmune blistering disorder that presents with flaccid oral or other mucosal bullae that rupture easily and leave erosions.

• Bullous pemphigoid is an autoimmune blistering disease that features tense bullae with pruritus as the predominant symptom

Question 22

Cervical cancer screening

Answer 22

Women aged 21-65 y with
#cytology (Pap smear) every 3 years
#HPV every 5 years (women older >25)
#HPV + cytology every 5 Years

Question 23

Cervical cancer screening when to discontinue

Answer 23

• Routine screening for cervical cancer can be discon- tinued at age 65 years in non-high-risk women, pro vided that the patient has undergone adequate prior screening.

• The U.S. Preventive Services Task Force defines ade- quate prior screening as three consecutive negative cytology results or two consecutive negative cytology tests plus human papillomavirus test results within the past 10 years, with the most recent test occurring within 5 years.

Question 24

Endometrial cancer

Answer 24

• Risk factors for endometrial cancer include obesity (BMI ≥30); a history of unopposed estrogen (e.g., poly- cystic ovary syndrome, obesity); or genetic syndromes, such as Lynch or Cowden syndrome.

• When presenting with abnormal uterine bleeding, women aged 45 years and older or those younger than 45 years who are at increased risk for endometrial cancer should undergo endometrial biopsy.

Question 25

Tinea corporis

Answer 25

• Tinea corporis is characterized by annular erythema- tous plaques with scale at the border.

• Diagnosis of tinea corporis is made by examination of the scale with potassium hydroxide; the presence of branching hyphae is diagnostic.

Question 26

Urticarial vasculitis

Answer 26

• Urticarial vasculitis is characterized by urticarial lesions that last longer than 24 hours and that burn and sting rather than itch; wheals that resolve with hyperpigmentation; and associated systemic symptoms, such as fever and joint pain.

• If urticarial vasculitis is suspected, skin biopsy is helpful diagnostically.

Question 27

HCW vaccination

Answer 27

• Health care workers are at increased risk for pertussis and should receive the tetanus toxoid, reduced diph- theria toxoid, and acellular pertussis vaccine regard- less of when they received their last tetanus and diph-

theria toxoids vaccine.

In addition to pertussis, health care workers are also at increased risk for influenza, hepatitis B, measles, mumps, rubella, and varicella viruses and should receive the appropriate vaccinations.

Question 28

Hpv vaccine

Answer 28

• Individuals aged 11 to 26 years should receive human papillomavirus vaccination, ideally administered between age 11 and 12 years or between age 13 and 26 years if not given previously.

Individuals younger than 15 years can receive a two-dose series, whereas those aged 15 years or older, such as this patient, should receive a three dose series.

• A history of human papillomavirus infection or an abnormal Pap smear does not change the recommendation for human papillomavirus vaccination.

Question 29

Bacterial prostatitis

Answer 29

• Bacterial prostatitis is associated with acute onset of local symptoms (dysuria, urinary frequency and urgency, suprapubic and/or perineal pain) and systemic symptoms (fevers, chills, nausea/vomiting, malaise).

• Oral trimethoprim-sulfamethoxazole or an oral fluoroquinolone (ciprofloxacin, levofloxacin) is an appro- priate empiric antibiotic for acute bacterial prostatitis

Question 30

Tinea pedis treatment

Answer 30

• Recommended treatment of localized tinea on non- hair-bearing skin is terbinafine or imidazole creams, such as miconazole, clotrimazole, and ketoconazole

Question 31

Post operative pulmonary complications prevention

Answer 31

• Perioperative prophylactic respiratory physiotherapy that includes increased mobility, sputum clearance, deep breathing exercise, and inspiratory muscle training reduces the incidence of postoperative pulmonary complications

• There is no benefit of incentive spirometry, with or without deep breathing exercises, in preventing post- operative pulmonary complications

Question 32

Androgen deficiency testing.

Answer 32

• The diagnosis of androgen deficiency should be made only when a patient has two separate early morning (8:00 AM) serum total testosterone levels less than 300 ng/dL (10.41 nmol/dL) combined with suggestive symptoms and/or signs.

• Free and bioavailable testosterone measurements should be reserved for patients with total testosterone levels in the low-normal range and for patients suspected of having alterations in sex hormone-binding globulin levels.

Question 33

Porphyria cutanea tarda

Answer 33

• Porphyria cutanea tarda is a photosensitive disorder that present with scarring and blistering on sun- exposed skin, most commonly on the dorsal hands.

• most commonly associated with hepatitis C virus infection, alcohol-induced liver disease, and hemochromatosis

Plasma and urine porphyrins should be measured to confirm the diagnosis

Treatment for PCT is phlebotomy or twice- weekly hydroxychloroquine.